Controversies in the Acute Management of High Spinal Cord
Injuries, an Update and Opinion Volume 1 - Issue 5
Nabil A Alageli*
Consultant orthopaedic and spine surgeon, Tripoli Medical Centre, Libya
Received: October 19, 2017; Published: October 26, 2017
Corresponding author: Nabil A Alageli, Consultant orthopaedic and spine surgeon, Tripoli Medical Centre, PO Box 80596, Zawia Street Office Tripoli,
Libya
The incidence of spinal cord injuries is the lowest of all major trauma, with devastating impact on the individual affected. The immediate
treatment, though it remains mainly supportive, in many situations will determine the outcome and the cost of health care. Standards of care
are unfortunately still lacking, this is mainly due to the existing controversies and lack of effective treatment of the injured cord. The author
discusses here some of the controversial points based on literature review and personal observation.
Abbreviations : MP: Methyl Prednisolone; NASCIS: National Acute spinal Cord Injuries Study; SDI: Spinal Decompression in Acute
It is well known that secondary insult to the spinal cord may
occur because of mechanical as well as physiological instability,
an injured cord will exhibit a cascade of pathological processes
involving immune mechanisms and mediators which will lead to
swelling of the cord rendering it susceptible to iatrogenic injury
including hypoxia and hypotension, this is found to be maximal at
24 hours. The argument for early surgery should mean that it is
carried out within 4 hours of injury i.e. before cord swelling become
apparent; complex, or lengthy surgery at the stage of spinal cord
oedema could be harmful. Reports exist that outcome of surgery
done at 24 to 72 hours is not associated with better neurological
improvement or shorter length of stay in hospital, at the same time
reported a high percentage of complications ranging between 24 to
41% [1-20].
It has to be noted that in cervical and upper thoracic cord
injuries,” surgical stabilisation is not synonymous with early
mobilisation “, that was mainly due to the multisystem physiological
dysfunction and instability associated with SCI, which may take few
weeks to settle. Optimum time for surgical intervention remains
a question and it is the opinion of the author that surgery is best
done within 4 hours of injury or be deferred later provided that
alignment of the spine is corrected and maintained by traction
in case of cervical spine injury and bed rest (postural reduction)
in thoracic injuries, this is in addition to the standard supportive
measures aimed at maintaining adequate cord perfusion and
oxygenation [20-30].
High Dose Methyl Prednisolone
Since the publication of the National Acute spinal Cord Injuries
Study (NASCIS) II, high dose methyl Prednisolone administration
in the first 8 hours became a standard treatment for the acutely
injured spinal cord. Evidence is now accumulating that there is no
appreciable functional improvement after such treatment despite
a modest improvement in motor scale, in addition it has been
shown that the study itself contain statistical artefacts. Although
steroids continue to be given to patients with spinal cord injury
in many institutions, evidence of deleterious effects continues to
accumulate. This controversy led to surgeons having to administer
the drug for fear of litigation rather than due to a belief in improved
clinical outcomes. After critical evaluation of the data available it is
concluded that there is no sufficient evidence to support the use of
MP in acute SCI [30-45].
Spinal Decompression in Acute SCI
It has been shown that many incomplete SCI patients,
neurologically & functionally improve after conservative treatment
and / or surgical stabilisation only without decompression of a
traumatic spinal stenosis. Also literature show that closed or open
reduction of dislocated facets in case of cervical spine offers a
satisfactory decompression especially in the first few hours after
injury, with good clinical outcome (in some series up to 85%) in
terms of neurological improvement. After critical analysis of the
available literature, there is clearly no correlation between the
percentage canal encroachment and the extent of neurological
deficit, also neurological recovery does not correlate with canal
decompression in acute trauma of the spinal cord. Neurological decompression and stabilisation, however is indicated in cases of
neurological deterioration due to epidural collection or inability to
maintain spinal alignment [45-55].
Management of acute SCI is still sub-optimum in many areas
due to the relative rarity of such devastating injury; more high
quality research is required to arrive at consistent standards of care
or protocols of management. It is the opinion of the author that the
need arises for the creation of spinal injuries centres covering a
wide population area, with an integrated multi-disciplinary input
and a comprehensive care routine of management from the early
hours of injury; this will undoubtedly solve the competency issue
of the treating team.